Appendix F
UNIVERSITY OF NORTHERN IOWA
AUTHORIZATION FOR PAYROLL DEDUCTION
_______________________________________________________________________________
Last Name First Name Middle Name
TO: University of Northern Iowa
I hereby request and authorize you to deduct from my earnings an amount sufficient
to provide for the regular payment of the current rate of monthly withholding
established by United Faculty. The amount shall be certified by the organization
noted and any change in such amount shall be so certified. The amount deducted
shall be paid to the organization shown with this form. This authorization shall
remain in full force and effect unless terminated by me with written notice to
my employer, as provided by law.
________________________________
Date
______________________________ ____________________________________
Employee's Signature Street Address
______________________________ ____________________________________
Social Security Number City and State
Cancellation of Authorization to Withhold Wages
Please be advised that I wish to cancel the above authorization to withhold wages
effective with the ___________________ payroll (as provided by law)
(month and year)
______________________________________ ______________________
Signature of staff member Date, month and year
termination agreement